Client Intake Form

U.S. Small Business Administration Form 641

PART I: Client Request for Services (To be completed by all clients)
Client Name*
(Name of the person completing the form/representative of the business) (Last, First, MI)
Email Address*
Contact Phone Number*
Street Address/PO Box
(Provide business address if currently in business)
City
State
Zip*
Preferred date & time for appointment* at  
PART II: Client Intake (To be completed by all clients)
Race
Select all that apply.







Other Race
Ethnicity*


Gender*


Age*




Low-To-Moderate Income*


Do you consider yourself a person with a disability?*


Education Level*
Please select highest.









Current Military Status*





Current or Highest Military Rank*







How did you find out about us?*
Select all that apply.

























Other
Internet Address
Are you currently in business?*
If no, skip to the final question below.


If yes, are you currently exporting?

Name of Business
Is your business in an urban or rural location?


Primary 6-digit NAICS Code:
(Enter 6-digit NAICS code. If you do not know the 6-digit NAICS code, write in the type of business below)
Primary Type of Business:
Business Ownership-What percentage of your business is male or female owned?
Male: %
Female: %
Date Business Started
Do you conduct business online?

Is your business on tribal lands?

Are you a home based business?

Total No. of Employees Including Yourself
Are you 8(a) certified?

Of total employees, how many are engaged in exporting?
For your most recent full business year, what were your:
Gross Revenues/Sales
+Profits/-Losses
How much of gross revenues were related to exporting?
As of the most recent full business year.
What percentage of gross revenues were related to exporting?
As of the most recent full business year.
%
What is the legal entity of your business?





What is the nature of the service you are seeking?*
Select all that apply.























Other Service

By clicking the SUBMIT button, I request business counseling or training from the Small Business Administration (SBA) and its partners and permit SBA to use my name, business address, and email address to contact me for customer service surveys or with information mailings regarding SBA products and services. I understand that any information disclosed will be held in strictest confidence by SBA. I authorize SBA to share relevant information about my request with the assigned management counselor(s). Please note: the estimated burden for completing this form is 25 minutes. You are not required to respond to any collection information unless it displays a current valid OMB approval number. Comments on the burden should be sent to: U.S. Small Business Administration, 409 3rd Street, SW, Washington, DC 20416, and to: Desk Officer SBA, Office of Management and Budget, New Executive Office Building, Suite 6054, Washington, DC, 20503. OMB Approval (3245-0324). PLEASE DO NOT SEND FORMS TO OMB.